=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164754362
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STACY LYNN OLINGER FUNCTIONAL NUTRITION
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/12/2010
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21819 MANSFIELD BLUFF LN
-----------------------------------------------------
City | SPRING
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77379
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-940-6165
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2211 RAYFORD RD SUITE 111-8
-----------------------------------------------------
City | SPRING
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 77386
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-940-6165
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number | 227008019
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 174H00000X
-----------------------------------------------------
Taxonomy Name | Health Educator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | MT119345
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------